Laserfiche WebLink
APPLICATION FOR PERMIT <br /> SAN JOAQUIN LOCAL HEALTH DISTRICT <br /> 1601 E. HAZE T ON AVE., STOCKTON, CA <br /> Telephone (209) 466-6781 <br /> PERMIT EXPIRES 1 YEAR FROM DATE ISSUED 17C� <br /> E _ (Complete in Triplicate) C, <br /> Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is <br /> made in compfiance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin <br /> Local Health District. <br /> Job Address City Lot Size PM <br /> Owner's Name •-✓i V �Ec, Address �'r +� Phone <br /> -D ' <br /> r; ed% g- (-�f �.& ros5 — —.r-4.T <br /> Contractor's NamekLy- ") '4 icense.No. YPhone — <br /> TYPE OF WELL/PUMP: NEW WELL WELL REPLACEMENT ❑ DESTRUCTIO, <br /> PUMP INSTALLATION ❑ SYSTEM REPA ❑ OTHER ❑ <br /> DISTANCE TO NEAREST: SEPTIC TANK tG' SEWER LINES Z�► DISPOSAL FLDh?_ Ff PROP. LINE <br /> FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS <br /> INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS <br /> Industrial 11 Open Bottom ❑ Manteca Dia, of Well Excavation ` Dia. of Well Casing <br /> ❑ Dom stic7Private Gravel Pack ❑ Tracy Type of Casing 5�� Specifications <br /> nE] Public ❑ Other ElDelta Depth of Grout Seal 5—dO ' Type of Grout �1 <br /> ❑ irrigation % /,IV-Approx. Depth ❑ Eastern Surfac Seal Installed by -r" ? <br /> Repair Work Done, El <br /> of Pump H.P. f State Work Donees-� <br /> Well Destruction ❑ Well Diameter Sealing Material Stop 501 <br /> Depth Filler Material (Below 501 <br /> PE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is <br /> available within 200 feet.) <br /> Installation' e: Residence_ Commercial Other <br /> Numberlof living units: Number of bedrooms <br /> - I <br /> I <br /> Character of soil to a depth of 3 -- - ------Water-table-depth- <br /> SEPTIC TANK ❑ Type/Mfg Capacity No. Compartments { <br /> PKG. TREATMENT PLT. ❑ Method of Disposal <br /> Distance to nearest: Well oundation Property Line <br /> LEACHING LINE ElNo. & Length of lines I length/size <br /> FILTER BED ❑ Distance to nearest: Well Foundation - r- Line <br /> SEEPAGE PITS ❑ Depth Size ` Number - <br /> SUMPS ❑ Distance to nearest: Well Foundation ' '`• Property Line <br /> I <br /> DISPOSAL PONDS ❑ <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and <br /> rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not <br /> employ any person in such manner as to become subject to workman's compensation laws of California." Contractor's hiring or sub-contracting signature <br /> certifies the following:"I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- <br /> tion laws of California." <br /> The applicant II for all required ' .pectin omplete drawing on reverse side. <br /> Signed Title: FX 0 Date: <br /> .� FOR DEPART T USE ONLY <br /> Application Accepted by v✓ Date (JAre_a1.;2- <br /> 1_)94Y9 <br /> . <br /> 1 '' " Date D v <br /> Pit o Grou Inspection by Date Final Inspection by_� <br /> Additional Comments: _ <br /> ❑ Stk 466-6781 Lodi 369-3621 ❑ Manteca 623-7104 ❑ Tracy 835-6385 <br /> Applicant- Return all opi to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.Q. Box 2009, Stk., CA 95201 <br /> FEE AMOUNT DUE AMOUNT REMITTED CR RECEIVED BY DATE I PERMIT•`NO... <br /> INFO CASH <br /> O <br /> +EH 1324IaEv. <br /> EH 1426 <br /> 4 <br />